Pancreas Flashcards
Surgery for chronic pancreatitis
> 6mm dilated. Will likely respond to surgery. Can do
puestow: roux-en-y pancreaticojejunostomy
Frey: subtotal ventral head resection (core out a chunk of the head) + pancreaticojejunostomy-
Beger: duo preserving panc head rxn -> you have two pancreatico-J’s here. One to the tail and one to the remainder of the head
What % of ppl with peripancreatic fluid collection will develop pseudocyst?
- what % will become symptomatic?
- what is the spontaneous regression rate?
- what % will become infected?
- about 5-15% will develop psuedocyst
- about half will develop symptoms
- 70% spontaneous regression rate
- about 1/3 will become infected
When doing a cystgastrostomy the anastomosis should be interrupted or running?
Interrupted full thickness. If running suture, may become loose when edema dies down
What is the T staging for pancreatic cancer?
T1: <2cmT2: >2cmT3: extension beyond pancreasT4: tumor involves celiac axis or sma
Patient with chronic pancreatitis. What’s the order of workup after CT showing dilated PD?
If any abnormality seen on CT -> endoscopic ultrasound to rule out mass
If no endoscopic ultrasound -> ERCP .
If proximal stricture then dilate + stent.
not MRCP
When doing a cystgastrostomy the anastomosis should be
partial thickness or full thickness?
running or interrupted?
Interrupted full thickness. If running suture, may become loose when edema dies down
Most common genetic abnormality for pancreatic cancer
KRAS2 in more than 95% of pancreatic cancers
Management of IMPN first based on what?
Communication to the duct (main duct and mixed type) -> resection
Branch duct:
<1cm: repeat CT annually
1-3cm: repeat CT in 6 mo. Then annually
>3cm: rxn to neg margin
What is the definition of a pancreatic leak?
Drain amylase > 3x serum on POD #3
How prevalent is pancreas divisum?
What is the treatment?
Up to 10% of population. More common in women in 3rd, 4th decade
ERCP, sphincterotomy/papillotomy of the minor papilla (Santorini)
Dorsal panc= body. In embryo, drained by Santorini into minor papilla
Ventral panc= head/neck. In embryo, drained by Wirsung into major papillaVentra
Describe the step up approach for pancreatic necrosis
1) perc drainage
2) if no improvement in 72hrs -> second drainage
3) if no improvement in 72hrs -> video assisted retroperitoneal debridement with post-op lavage
Describe the classification of fluid collections in acute pancreatitis
Necrosis -> acute necrotic collection -> 4 wks -> walled off necrosis
No necrosis -> acute peripancreatic collection -> 4 wks -> paeudocyst
How much does smoking increase the risk for pancreatic cancer?
Smoking increases risk by ~75%Alcohol increases risk by 20-30%Chronic pancreatitis: 5-7% lifetime risk
Dry mouth, eyes, elevated IgG4. Diagnosis?
Associated with what other syndrome?
Autoimmune pancreatitis
Male > female 2:1
Associated with antiphospholipid syndrome
Surgical treatment option for hereditary pancreatitis?
Total pancreatectomy and auto islet transplantation
Where do the ant/post superior pancreaticoduodenal arteries come from?
What about ant/post inferior pancreaticoduodenal arteries?
Where does the dorsal pancreatic artery come from?
Superior: from celiac -> GDA
Inferior: from branches of the SMA
Dorsal pancreatic: from splenic
What can you use for metastatic or recurrent unresectable insulinomas?
Streptozotocin or
Diazoxide
Pancreatic neuroendocrine tumor. Which one is mostly benign? Mostly malignant?
All are malignant and maybe metastatic at diagnosis except insulinomas.
Insulinomas: ~10% malig
What is Verner-Morrison syndrome?
WDHA syndrome
Watery
Diarrhea
Hypokalemia
Achlorhydia
VIP, PPP, GIO secreting tumors
~50% malig. Most metastatic at diagnosis
Resection is possible. Streptozocin/diazoxide
Somatostatin
Ransom criteria mortality prediction is more accurate for alcoholic or biliary pancreatitis?
EtOH
What are the success rates for chronic pancreatitis surgery if the duct is dilated vs not?
What surgeries do you do if the duct is not dilated?
60-70% success rate if duct is dilated. Puestow
<50% success rate if the duct is not dilated. Resect them. Whipple, Beger, or Frey, or celiac plexus blockade
Beger: duodenum preserving panc head rxn. RNY panc head-J, panc tail-J. Two anastomoses
Frey: subtotal ventral head resection and drainage. CORE out the head and do RNY panc-J
Difference in surgical treatment between communicating vs non-communicating pancreatic pseudocyst?
Communicating: always drain into jejunum. RNY cyst-jejunostomy
Non-communicating: RNY cyst jejunostomy, cyst-gastrostomy, cyst-duodenuostomy
What’s the 5yr survival for resectable pancreatic cancer +/- neoadjuvant chemo?
Surgery alone: 18% With neoadjuvant: ~30%
Which pancreatic lesions?
Immunohistochemical staining demonstrates nuclear localization of beta-catenin
Pseudopapillary neoplasm
Which pancreatic lesion?
Ovarian stroma
Mucinous cystic neoplasm
Which pancreatic lesion?
Fish mouth
IPMN produces mucin protruding through the ampulla
Pancreatic lesion with chromogranin A?
Any pancreatic neuroendocrine tumor. ~10% will be chromogranin A (+)
What does acid-Schiff stain stain?
Which pancreatic lesion?
Glycogen.
Serous cystic neoplasm
Splenic artery is in what relationship to the pancreas?
Superior to the pancreas
For IPMN which of the following feature should trigger an operation?
- presence of mucin in aspirate
- mural nodularity
- cyst fluid CEA > 200
Mural nodularity -> definite predictor of malignancy
What is a worrisome CEA level from a pancreatic cyst?
> 192
What is a worrisome/high risk duct size for pancreatic cyst?
5-9mm: worrisome
>10mm: high risk
What is the gold standard for diagnosing chronic pancreatitis?
What is the first line test for the diagnosis of chronic pancreatitis?
Gold standard: biopsy for tissue analysis
First line: CT
What % of necrotic pancreatic collection will become infected?
1/3
What is the sensitivity of CT and ERCP for diagnosis of pancreatic cancer?
CT: 85%
ERCP: 90%
However ERCP is not routinely used due to the invasive nature. Only if CT can’t identify lesions for obstructive jaundice
Which pancreatic enzyme clears the fastest in the course of pancreatitis?
Amylase clears in less than 48 hrs but a level > 150 in the first 72 hrs is a consistent finding
Lipase remains elevated for >96hrs
Pancreatic polypeptide [stimulates/inhibits] pancreatic secretions
Inhibits actually
What is the most sensitive test for chronic pancreatitis?
most sensitive: Postprandial pancreatic polypeptide hormone level
gold standard: tissue biopsy
first test: CT
